January 11, 2016 — As Medicaid programs in at least 34 states restrict coverage for Harvoni and Sovaldi, a growing number of patients with hepatitis C are being told they are not sick enough for treatment.
One victim, Sarah Jackson, has joined a class action lawsuit and spoke with NPR. She has hepatitis C and was prescribed Harvoni by her doctor, but has not started treatment.
Indiana’s Medicaid program denied coverage for Harvoni because she does not yet have liver damage. According to her attorney: “If something is medically necessary, it’s medically necessary and must be covered by the Medicaid program.”
In November, the Center for Medicare and Medicaid Services sent a letter reminding states that they cannot restrict coverage for drugs that are prescribed for medically necessary conditions.
The problem is that Sovaldi and Harvoni are extremely expensive — up to $95,000 for a 12-week treatment with Harvoni. According to the Chicago Tribune, the same $1,000 pill sells for just $4 in India.
Critics of the restrictions say the up-front costs are justified by the long-term benefits, including a reduced cost of treating complications and eliminating the risk of transmitting hepatitis C to another person.
The World Health Organization (WHO) estimates that 3 million people in the United States have hepatitis C, out of 150 million worldwide. Hepatitis C is a highly-contagious virus that spreads in blood and bodily fluids, often on dirty needles or medical equipment. Infection causes liver inflammation and scarring that can lead to liver failure and death.